059-17 Wyo. Code R. §§ 17-16 - Hazardous Drugs as CSPs

(a) Hazardous drugs shall be prepared for administration only under conditions that protect personnel in the preparation and storage areas.

(b) Pharmacy staff shall store hazardous drugs separately from other inventory, in a manner to prevent contamination and personnel exposure.

(c) Pharmacy staff shall handle hazardous drugs with caution at all times using appropriate chemotherapy gloves during receiving, distributions, stocking, inventorying, preparation for administration, and disposal.

(d) Hazardous drugs shall be prepared in a BSC or CACI with ISO Class 5 or better air quality.

(e) CSTDs shall be used when the compounding process allows.

(f) A hazardous drug buffer room shall maintain a minimum differential negative pressure of 0.01-inch water column between the buffer room and the ante-room.

(g) The pharmacy shall limit access to areas where hazardous drugs are stored and prepared to protect persons not involved in drug preparation.

(h) Compounding pharmacy staff shall wear PPE when compounding in a BSC or CACI and when using CSTDs.

(i) PPE shall include gowns, face masks, eye protections, hair covers, shoe covers or dedicated shows, and double gloving with sterile chemo-type gloves.

(i) All pharmacy staff who handle or compound hazardous drugs shall be fully trained in the storage, handling, and disposal of hazardous drugs.

(i) Training shall occur prior to preparing or handling hazardous CSPs;

(ii) Training shall be documented for each person, at least annually; and

(iii) Training shall include, but is not limited to the following:

(A) Didactic overview of hazardous drugs in the pharmacy, including mutagenic, teratogenic, and carcinogenic properties;

(B) Ongoing training for each new hazardous drug in the pharmacy;

(C) Pharmacy staff of reproductive capability shall confirm, in writing, that they understand the risks of handling hazardous drugs;

(D) Safe aseptic manipulation practices;

(E) Negative pressure techniques when utilizing a BSC or CACI;

(F) Correct use of CSTDs;

(G) Containment, cleanup, and disposal procedures for breakages and spills; and

(H) Treatment of pharmacy staff in the event of contact and inhalation exposure.

(j) Pharmacy staff shall comply with applicable state and federal regulations when disposing of hazardous drugs.

(k) While preparing hazardous drugs for emergency use, pharmacy staff may compound the hazardous drug outside of a PEC, so long as a CSTD and PPE for hazardous drug compounding are used.

Notes

059-17 Wyo. Code R. §§ 17-16

Adopted, Eff. 5/13/2021.